tag:blogger.com,1999:blog-2760353953251845523.post4154620209757881992..comments2015-03-03T16:37:21.329-05:00Comments on Buckeye Surgeon: GawandeJeffrey Parks MD FACShttp://www.blogger.com/profile/15650563299849196122noreply@blogger.comBlogger13125tag:blogger.com,1999:blog-2760353953251845523.post-4109456521475314122009-06-21T11:00:21.075-04:002009-06-21T11:00:21.075-04:00Buckeye - Nice post and I agree with much of your ...Buckeye - Nice post and I agree with much of your analysis. However, one of your statements was particularly interesting:<br /><br />&quot;The issue of cost never crosses his mind.&quot;<br /><br />I agree that this is the norm but is this really acceptable? How can we ever expect costs to be contained when this is the culture. I don&#39;t know of any other industry where this is the accepted norm (or if it is, those companies aren&#39;t in business for too long). We, as physicians, must be more conscious of cost. If we aren&#39;t, the government will eventually do it for us (e.g fee for service medicine of 1980s).Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-41569923888682206822009-06-20T17:41:01.799-04:002009-06-20T17:41:01.799-04:00We should also mention how over-testing can lead t...We should also mention how over-testing can lead to worse patient outcomes. A glaring example would be the patients I see as a resident at an academic hospital, who finally get referred to our pancreatic surgeon for a Whipple - after spending three to four months having one EGD/ERCP after another, a CT, an MRCP, one or two ultrasounds, then an EUS - when it was perfectly clear from the initial presentation (60yo, weight loss, painless jaundice, strictured CBD with no history to suggest a benign cause) that the patient likely had cancer. They should have been sent to the surgeon within weeks of presentation, after just one ERCP and EUS. (ie, don&#39;t do repeat ERCPs trying to get pathology to prove the diagnosis, if your first brushing was indeterminate. The presentation and a few imaging abnormalities are enough to warrant surgical evaluation.) It&#39;s impossible to prove with data, but it makes me sick to think how many of these patients have their cancer metastasize during the months of needlessly repetitive workup.Alicehttp://cutonthedottedline.wordpress.comnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-47360703458057268672009-06-19T22:27:29.695-04:002009-06-19T22:27:29.695-04:00VLaz-
I feel your pain...Funny stuff/VLaz-<br />I feel your pain...Funny stuff/Buckeye Surgeonhttp://www.blogger.com/profile/15650563299849196122noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-641082365061430132009-06-19T22:21:53.843-04:002009-06-19T22:21:53.843-04:00Your analysis is right on the money. The over-test...Your analysis is right on the money. The over-testing and over-treating is a failure of primary care, and especially of the doctor-patient relationship. We have allowed and encouraged patients to believe that more tests and more procedures is better medicine.<br /><br />I shudder to think how much WORSE it is going to get when more and more of the primary care is provided by nurse practitioners and PAs. <br /><br />I mean they send me patients with lipomas or even big sebaceous cysts to excise - and most of the patients have had ultrasounds done. Some have even had CTs!! They could just call me and save a bunch of money for the system, but no. Or they send me patients with obvious IBS by Rome criteria for a workup &quot; including possible upper and lower endoscopy &quot;, or the ladies with slight dyspepsia and a negative GB ultrasound but a GB ejection fraction of 27% on the equally unnecessary HIDA.<br /><br />I remember a lady sent to me for a hernia repair. She wanted to be sure her cardiologist got to go over all her pre-op workup. She was 52 years old with absolutely no medical problems and no medications. Before I told her that I thought she did not need ANY pre-operative workup at all I had to ask her, &quot;Why do you have a cardiologist? You have no heart disease. &quot; &quot;Well, I had some palpitations once and there was something on my EKG so my doctor sent me to a cardiologist. They did a lot of tests and finally said I was completely fine.&quot; &quot;So, you have nothing wrong with your heart, right? So why do you have a cardiologist?&quot; And you know what? - If you tell one of these people that they don&#39;t need any more tests, or they don&#39;t need that operation THEY THINK YOU ARE A BAD DOCTOR.<br /><br />Oy vey.Victor Lazaronhttp://www.blogger.com/profile/11634100793910465958noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-69015541116425479562009-06-19T21:56:52.510-04:002009-06-19T21:56:52.510-04:00buckeye,
I agree with you through most of your po...buckeye,<br /><br />I agree with you through most of your post but like the disconnect you noted between the mention of PCP mindset and the final solutions offered in Gawande&#39;s piece, in your post you do something similar. <br /><br />Your give two sources of the problem: overworked PCPs and those being trained to run every lab to ensure patient care/cover their ass. <br /><br />At the end of your post you state possible solutions, &quot;altering the way they practice medicine, how and when they order consults, incentivizing them financially to do more of the work on their patients themselves&quot;. So how do we incentivize them to do more work? How about reducing workload through increasing PCP numbers, or reducing incentive to race through patients, by keeping physicians salaried like at Mayo.<br /><br />You make a great point that McAllen is an outlier and one to be used as an example of a flawed system. But how about focusing on Mayo, another outlier, as a system to be modeled after?<br /><br />The culture of fear in our country all to often focusing efforts on avoiding those worst case scenario outliers such as McAllen instead of aiming for the Mayo&#39;s.Robienoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-4793331055833666712009-06-19T14:07:06.438-04:002009-06-19T14:07:06.438-04:00Nice post.
What was missing from the McAllen piec...Nice post.<br /><br />What was missing from the McAllen piece was any kind of followup on an individual patient whom Gawande was suggesting they were inappropriately treated, and then go back to the patient and the doctor with the particulars of the case. Otherwise we get a useless lump of data with mean expenditures.<br /><br />I would assume it&#39;s clearly cardiology, GI, arthrodcopic knee/shoulder surgery, and imaging studies which drive the excess on the clinical side. It was interesting to note in McAllen that home health expenditures were more then 50% of the excess cost per Medicare benificiary. Clearly too much of that service is being orderedDr. Rob Oliver Jr.http://www.blogger.com/profile/09059882318849767896noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-71631822050319413562009-06-19T11:49:56.648-04:002009-06-19T11:49:56.648-04:00Ron Paul on healthcare
http://www.youtube.com/wat...Ron Paul on healthcare<br /><br />http://www.youtube.com/watch?v=foXQbmZxWYYTrader Bobhttp://www.blogger.com/profile/10900345653035497739noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-36807852701309843422009-06-18T11:36:20.120-04:002009-06-18T11:36:20.120-04:00Good point, buckeye.
Gawande would flunk out of a...Good point, buckeye.<br /><br />Gawande would flunk out of an elementary statistical inference class.<br /><br />Proving cause and effect is a lot more complicated<br />than a simple quantitative analysis of one sample from a distribution. The fact that the sample is the biggest<br />outlier almost demonstrates incompetence.<br /><br />He needs to show that his hypothesis holds true by comparing two groups. Groups of one mean versus groups of another mean.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-52402549137961112012009-06-17T22:44:07.286-04:002009-06-17T22:44:07.286-04:00ABC News is refusing paid ads for its health care ...ABC News is refusing paid ads for its health care program at the White House. Conservatives for Patients Rights (CPR) inquired about purchasing ad time and was willing to do so. As of now, ABC is not accepting paid advertising, thus they&#39;re refusing even a paid-for alternative viewpoint. Here is statement from Rick Scott, chairman of Conservatives for Patients Rights. We remain hopeful ABC News will reconsider.<br /><br />&quot;It is unfortunate - and unusual - that ABC is refusing to accept paid advertising that would present an alternative viewpoint for the White House health care program. Health care is an issue that touches every American and all potential pieces of legislation have carried a price tag in excess of $1 trillion of taxpayers&#39; money. The American people deserve a healthy, robust debate on this issue and ABC&#39;s decision - as of now - to exclude even paid advertisements that present an alternative view does a disservice to the public. Our organization is more than willing to purchase ad time on ABC to present an alternative viewpoint and our hope is that ABC will reconsider having such viewpoints be part of this crucial debate for the American people. We were surprised to hear that paid advertisements would not be accepted when we inquired and we would certainly be open to purchasing time if ABC would reconsider.&quot; <br /><br />The media controls the minds of Americans. The fascist government state we live in is bed with big business including the corporate media. So America is going to believe that Obamacare is the answer. Just like giving the Federal Reserve the power to control the financial system is the right answer. <br /><br /><br />Problem, big business is in bed with government. Reaction, the people know we are being misled and want to choke slam their leaders. Solution, more government from the clowns in Washington and the Federal Reserve. I don&#39;t have the answers but more government and more taxes is not the answer.<br /><br />These quotes are a little extreme but I see some trends that I don&#39;t like.<br /><br />Fascism should more appropriately be called Corporatism because it is a merger of state and corporate power. <br />Benito Mussolini <br /><br />The goal of socialism is communism. <br />Vladimir Lenin <br /><br />A lie told often enough becomes the truth. <br />Vladimir Lenin <br /><br />This country is not going in the right direction.Trader Bobhttp://www.blogger.com/profile/10900345653035497739noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-48262939989242926312009-06-17T21:41:43.122-04:002009-06-17T21:41:43.122-04:00Buckeye,
i sense that you are a bit jaded by th...Buckeye,<br /> i sense that you are a bit jaded by the PCP&#39;s in your area. I tend to disagree with you though that this is how it is everywhere. I guess my practice style and that of my partners is very different. We really only consult when we need a procedure done that we do not perform. I see the other side:<br />when i consult a cardiologist it goes something like...stress,echo, etc<br />A pulmonologist=PFT&#39;s, HRCT, etc<br />A surgeon for RUQ pain c/w cholecystitis= CT/US/and the damn HIDA!<br />I try very hard to get patients in and out in a very timely fashion and my LOS is well below the average. People get sicker the longer they stay in the hospital and more deconditioned. Any test that can be done as an outpatient should be done that way.<br />The other side of this is ED doctors. Every patient seen seems to need to be admitted. The patient with known CHF that has a little worse edema and sob without hypoxia or ischemia can be diuresed and discharged with changes to their regimen. This is exactly what i would do in the office if that patient walked in that way. I try to make decisions for hospital and ED patients based on what i would do if that patient walked in my office. Every damn patient with CP or SOB gets a BNP drawn and a ct scan of the chest. Noone wants to make the CLINICAL decision and that is frustration and costs our medical system billions. I went into Internal Medicine because if the critical decision making that i thought it took to be good at it. That&#39;s what many people have to get back to doing instead of being scared and pan-consulting. I babble on. Thanks for the time to rantHudsonMDhttp://www.blogger.com/profile/05955328271938173408noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-36187149849890418552009-06-17T16:29:20.846-04:002009-06-17T16:29:20.846-04:00Excellent analysis.There is both much more( the mo...Excellent analysis.There is both much more( the more nuanced aspects you describe) and much less (you are right, by definition south Texas is an outlier and not the norm) that is implied(claimed)in the viral McAllen &quot;expose&quot;.With 40 years logged in the practice book my experience is more like yours as regards greed or the lack of it as the major driver in doctor&#39;s behavior. Often it is not what you say but where you get it printed.james gaultehttp://www.blogger.com/profile/05537303135780186926noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-12245397485276776202009-06-17T16:12:57.116-04:002009-06-17T16:12:57.116-04:00Josh-
If McAllen is the most expensive healthcare ...Josh-<br />If McAllen is the most expensive healthcare region in America, then by definition (think of bell curves, means and modes), it isn&#39;t all that common. Certainly practice habits as described in McAllen are prevalent in most other places. But obviously it doesn&#39;t happen to the extent it does in south Texas.Buckeye Surgeonhttp://www.blogger.com/profile/15650563299849196122noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-23775796277815789042009-06-17T16:01:22.039-04:002009-06-17T16:01:22.039-04:00I actually don&#39;t think the type of medicine he...I actually don&#39;t think the type of medicine he describes in McAllen is all that rare, as you are arguing. Maybe you have been more fortunate in some of the places you have practiced. All I know is that so much of what he described was far too similar to what I observe every day. From the automatic &#39;ever colonoscopy gets an EGD too for whatever reason&#39; to &#39;well, I&#39;m squirting the heart so I might as well squirt the legs and throw some stents in those too, even though I didn&#39;t do an H&amp;P ahead of time to even find out whether there was even the hint of an issue&#39;. I wish I could share our optimism about the physician populace, but I think its far more prevalent mindset/practice environment than you are suggesting.Joshnoreply@blogger.com